Optimizing the Time and Dose of Melatonin as a Sleep-Promoting Drug: A Systematic Review of Randomized Controlled Trials and Dose-Response Meta-Analysis

Previous studies have reported inconsistent results about exogenous melatonin's sleep-promoting effects. A possible explanation relies on the heterogeneity in administration schedule and dose, which might be accountable for differences in treatment efficacy. In this paper, we undertook a systematic review and meta-analysis of double-blind, randomized controlled trials performed on patients with insomnia and healthy volunteers, evaluating the effect of melatonin administration on sleep-related parameters. The standardized mean difference between treatment and placebo groups in terms of sleep onset latency and total sleep time were used as outcomes. Dose-response and meta-regression models were estimated to explore how time of administration, dose, and other treatment-related parameters might affect exogenous melatonin's efficacy. We included 26 randomized controlled trials published between 1987 and 2020, for a total of 1689 observations. Dose-response meta-analysis showed that melatonin gradually reduces sleep onset latency and increases total sleep time, peaking at 4 mg/day. Meta-regression models showed that insomnia status (β = 0.50, p < 0.001) and time between treatment administration and the sleep episode (β = -0.16, p = 0.023) were significant predictors of sleep onset latency, while the time of day (β = -0.086, p < 0.01) was the only significant predictor of total sleep time. Our results suggest that advancing the timing of administration (3 h before the desired bedtime) and increasing the administered dose (4 mg/day), as compared to the exogenous melatonin schedule most used in clinical practice (2 mg 30 min before the desired bedtime), might optimize the efficacy of exogenous melatonin in promoting sleep.

High-Intensity Aphasia Intervention Is Minimally Fatiguing in Chronic Aphasia: An Analysis of Participant Self-Ratings From a Large Randomized Controlled Trial

BACKGROUND

High-intensity therapy is recommended in current treatment guidelines for chronic poststroke aphasia. Yet, little is known about fatigue levels induced by treatment, which could interfere with rehabilitation outcomes. We analyzed fatigue experienced by people with chronic aphasia (>6 months) during high-dose interventions at 2 intensities.

METHODS

A retrospective observational analysis was conducted on self-rated fatigue levels of people with chronic aphasia (N=173) collected during a previously published large randomized controlled trial of 2 treatments: constraint-induced aphasia therapy plus and multi-modality aphasia therapy. Interventions were administered at a higher intensity (30 hours over 2 weeks) or lower intensity (30 hours over 5 weeks). Participants rated their fatigue on an 11-point scale before and after each day of therapy. Data were analyzed using Bayesian ordinal multilevel models. Specifically, we considered changes in self-rated participant fatigue across a therapy day and over the intervention period.

RESULTS

Data from 144 participants was analyzed. Participants were English speakers from Australia or New Zealand (mean age, 62 [range, 18-88] years) with 102 men and 42 women. Most had mild (n=115) or moderate (n=52) poststroke aphasia. Median ratings of the level of fatigue by people with aphasia were low (1 on a 0-10-point scale) at the beginning of the day. Ratings increased slightly (+1.0) each day after intervention, with marginally lower increases in the lower intensity schedule. There was no evidence of accumulating fatigue over the 2- or 5-week interventions.

CONCLUSIONS

Findings suggest that intensive intervention was not associated with large increases in fatigue for people with chronic aphasia enrolled in the COMPARE trial (Constraint-Induced or Multimodality Personalised Aphasia Rehabilitation). Fatigue did not change across the course of the intervention. This study provides evidence that intensive treatment was minimally fatiguing for stroke survivors with chronic aphasia, suggesting that fatigue is not a barrier to high-intensity treatment.

Postoperative Time and Anatomic Location Influence Skin Graft Reperfusion Assessed With Laser Speckle Contrast Imaging

OBJECTIVES

Under optimal conditions, afferent and efferent human skin graft microcirculation can be restored 8-12 days postgrafting. Still, the evidence about the reperfusion dynamics beyond this period in a dermato-oncologic setting is scant. We aimed to characterise the reperfusion of human skin grafts over 4 weeks according to the necrosis extension (less than 20%, or 20%-50%) and anatomic location using laser speckle contrast imaging (LSCI).

METHODS

Over 16 months, all eligible adults undergoing skin grafts following skin cancer removal on the scalp, face and lower limb were enroled. Perfusion was assessed with LSCI on the wound margin (control skin) on day 0 and on the graft surface on days 7, 14, 21 and 28. Graft necrosis extension was determined on day 28.

RESULTS

Forty-seven grafts of 47 participants were analysed. Regardless of necrosis extension, graft perfusion equalled the control skin by day 7, surpassed it by day 21, and stabilised onwards. Grafts with less than 20% necrosis on the scalp and lower limb shared this reperfusion pattern and had a consistently better-perfused centre than the periphery for the first 21 days. On the face, the graft perfusion did not differ from the control skin from day 7 onwards, and there were no differences in reperfusion within the graft during the study.

CONCLUSION

Skin graft reperfusion is a protracted process that evolves differently in the graft centre and periphery, influenced by postoperative time and anatomic location. A better knowledge of this process can potentially enhance the development of strategies to induce vessel ingrowth into tissue-engineered skin substitutes.

A critical analysis of the decreasing trends in tuberculosis cure indicators in Brazil, 2001-2022

OBJECTIVE

To analyze the temporal trend of tuberculosis cure indicators in Brazil.

METHODS

An ecological time-series study using administrative data of reported cases of the disease nationwide between 2001 and 2022. We estimated cure indicators for each federative unit (FU) considering individuals with pulmonary tuberculosis, tuberculosis-HIV coinfection, and those in tuberculosis retreatment. We used regression models using joinpoint regression for trend analysis, reporting the annual percentage change and the average annual percentage change.

RESULTS

For the three groups analyzed, we observed heterogeneity in the annual percentage change in the Brazilian FUs, with a predominance of significantly decreasing trends in the cure indicator in most FUs, especially at the end of the time series. When considering national indicators, an average annual percentage change of -0.97% (95% CI: -1.23 to -0.74) was identified for the cure of people with pulmonary tuberculosis, of -1.11% (95% CI: -1.42 to -0.85) for the cure of people with tuberculosis-HIV coinfection, and of -1.44% (95% CI: -1.62 to -1.31) for the cure of people in tuberculosis retreatment.

CONCLUSIONS

The decreasing trends of cure indicators in Brazil are concerning and underscore a warning to public authorities, as it points to the possible occurrence of other treatment outcomes, such as treatment discontinuity and death. This finding contradicts current public health care policies and requires urgent strategies aiming to promote follow-up of patients during tuberculosis treatment in Brazil.

Robotic versus laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011.

OBJECTIVES

To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results.

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

BACKGROUND

This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated.

OBJECTIVES

To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies.

SELECTION CRITERIA

We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence).

AUTHORS' CONCLUSIONS

For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.

Effects of extraoral storage time on autologous gingival graft early healing: A split-mouth randomized study

AIMS

Despite the established use of palatal tissue grafts for mucogingival procedures, there are no studies on the effect of extraoral storage time on graft outcomes. This prospective split-mouth randomized experimental clinical trial aimed to assess whether gingival graft extraoral storage time affects graft healing.

METHODS

Standardized grafts were harvested from the palate and stored extraorally for 2 (Control) or 40 (Test) minutes before being placed at recipient beds. Intraoral scans, clinical photographs, and tissue blood perfusion were obtained preoperatively, postoperatively, and at follow-up visits (Days 2 (PO2), 3 (PO3), 7 (PO7), and 14 (PO14)). Healing Score Index (HSI) and wound fluid (WF) biomarkers (angiogenin, IL-6, IL-8 (CXCL8), IL-33, VEGF-A, and ENA-78 (CXCL5)) were also assessed.

RESULTS

Twenty-three participants completed all study visits. Extraoral storage time was 2.3 ± 1.1 min and 42.8 ± 3.4 min for C and T grafts, respectively (p < .0001). Recipient beds remained open for 21.4 ± 1.7 min. No graft underwent necrosis or failed to heal by PO14. Minimal volumetric changes were observed, without significant intergroup differences (p ≥ .11). Graft perfusion initially decreased post-harvesting before peaking on PO7 for both C and T grafts, with no significant intergroup differences (p ≥ .14). HSI values progressively increased, with no significant intergroup differences (p ≥ .22). WF analysis revealed detectable levels for all biomarkers tested, without significant intergroup differences (p ≥ .23).

CONCLUSION

Extraoral storage time of 40 min has neither statistically significant nor clinically discernible effects on autologous graft revascularization, early healing, or survival, as determined by physiological, wound healing, and molecular parameters.

Home versus in-centre haemodialysis for people with kidney failure

BACKGROUND

Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs.

SELECTION CRITERIA

RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data.

MAIN RESULTS

From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence).

AUTHORS' CONCLUSIONS

Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.

Trends in mortality from gastrointestinal, hepatic, and pancreatic cancers in the United States: A comprehensive analysis (1999-2020)

Background and Aim

This study investigates temporal trends in gastrointestinal cancer-related mortality in the United States between 1999 and 2020, focusing on differences by sex, age, and race.

Methods

We investigated the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research multiple causes of death database (Years 1999-2020) for gastrointestinal cancer-related mortality with a focus on the underlying cause of death.

Results

A total of 3 115 243 gastrointestinal cancer-related deaths occurred from 1999 to 2020. The overall age-adjusted mortality rate decreased from 46.7 per 100 000 in 1999 to 38.4 per 100 000 in 2020. The average annual percent change (AAPC) for the study period was -0.9% (95% CI: -1.0%, -0.9%, P < 0.001), with no significant difference in AAPC between the sexes but some difference between races and related to individual cancers. African Americans and Asian Americans, and Pacific Islanders experienced a greater decrease in mortality compared with Whites. Mortality rates for American Indian and Alaskan Native populations also decreased significantly from 1999 to 2020 (P < 0.001). There were significant declines in esophageal, stomach, colon, rectal, and gallbladder cancer-related mortality but increases in the small bowel, anal, pancreatic, and hepatic cancer-related mortality (P < 0.001), with variation across different sexes and racial groups.

Conclusion

While overall gastrointestinal cancer-related mortality declined significantly in the United States from 1999 to 2020, mortality from some cancers increased. Furthermore, differences between sexes and racial groups underscore crucial differences in gastrointestinal cancer mortality, highlighting areas for future research.

Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery

BACKGROUND

The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group.

METHODS

In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient.

RESULTS

A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation.

CONCLUSIONS

Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

Age-Related Changes in Temporal Binding Involving Auditory and Vestibular Inputs

Maintaining balance involves the combination of sensory signals from the visual, vestibular, proprioceptive, and auditory systems. However, physical and biological constraints ensure that these signals are perceived slightly asynchronously. The brain only recognizes them as simultaneous when they occur within a period of time called the temporal binding window (TBW). Aging can prolong the TBW, leading to temporal uncertainty during multisensory integration. This effect might contribute to imbalance in the elderly but has not been examined with respect to vestibular inputs. Here, we compared the vestibular-related TBW in 13 younger and 12 older subjects undergoing 0.5 Hz sinusoidal rotations about the earth-vertical axis. An alternating dichotic auditory stimulus was presented at the same frequency but with the phase varied to determine the temporal range over which the two stimuli were perceived as simultaneous at least 75% of the time, defined as the TBW. The mean TBW among younger subjects was 286 ms (SEM ± 56 ms) and among older subjects was 560 ms (SEM ± 52 ms). TBW was related to vestibular sensitivity among younger but not older subjects, suggesting that a prolonged TBW could be a mechanism for imbalance in the elderly person independent of changes in peripheral vestibular function.

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Infant mortality in the municipality of São Paulo: trend and social inequality (2006-2019)

OBJECTIVE

Considering the published evidence on the impact of recent economic crises and the implementation of fiscal austerity policies in Brazil on various health indicators, this study aims to analyze how the trend and socio-spatial inequality of infant mortality behaved in the municipality of São Paulo from 2006 to 2019.

METHODS

This is an ecological study with a temporal trend analysis that was developed in municipality of São Paulo, using three residence area strata differentiated according to their social vulnerability following the 2010 São Paulo Social Vulnerability Index. Infant mortality rate, as well as neonatal, and post-neonatal mortality rates, were calculated for each social vulnerability stratum, each year in the period, and for the first and last three triennia. Temporal trends were analyzed by the Prais-Winsten regression model and inequality magnitude, by rate ratios.

RESULTS

We found a decline in infant mortality rate and its components from 2006 to 2015, greater in the stratum with low social vulnerability and in the post-neonatal period when compared to the neonatal one. This decline ended in 2015, stagnating in the next period (2016-2019). Our analysis of infant mortality inequality across social vulnerability stratum showed a significant increase from the initial to the final triennia in the analyzed period; rate ratios increased from 1.36 to 1.48 in the high stratum (compared to the low social vulnerability stratum), and from 1.19 to 1.32 between the medium and low social vulnerability strata.

CONCLUSIONS

The observed stagnation of infant mortality rate decline in 2015 and the increase in socio-spatial inequality point to the urgent need to reformulate current public policies to reverse this situation and reduce inequalities in the risk of infant death.

Analysis of hospital and payer costs of care: aggressive warming versus routine warming in abdominal major surgery

Background

Hypothermia is common and active warming is recommended in major surgery. The potential effect on hospitals and payer costs of aggressive warming to a core temperature target of 37°C is poorly understood.

Methods

In this sub-analysis of the PROTECT trial (clinicaltrials.gov, NCT03111875), we included patients who underwent radical procedures of colorectal cancer and were randomly assigned to aggressive warming or routine warming. Perioperative outcomes, operation room (OR) scheduling process, internal cost accounting data from the China Statistical yearbook (2022), and price lists of medical and health institutions in Beijing were examined. A discrete event simulation (DES) model was established to compare OR efficiency using aggressive warming or routine warming in 3 months. We report base-case net costs and sensitivity analyses of intraoperative aggressive warming compared with routine warming. Costs were calculated in 2022 using US dollars (USD).

Results

Data from 309 patients were analyzed. The aggressive warming group comprised 161 patients and the routine warming group comprised 148 patients. Compared to routine warming, there were no differences in the incidence of postoperative complications and total hospitalization costs of patients with aggressive warming. The potential benefit of aggressive warming was in the reduced extubation time (7.96 ± 4.33 min vs. 10.33 ± 5.87 min, p < 0.001), lower incidence of prolonged extubation (5.6% vs. 13.9%, p = 0.017), and decreased staff costs. In the DES model, there is no add-on or cancelation of operations performed within 3 months. The net hospital costs related to aggressive warming were higher than those related to routine warming in one operation (138.11 USD vs. 72.34 USD). Aggressive warming will have an economic benefit when the OR staff cost is higher than 2.37 USD/min/person, or the cost of disposable forced-air warming (FAW) is less than 12.88 USD/piece.

Conclusion

Despite improving OR efficiency, the economic benefits of aggressive warming are influenced by staff costs and the cost of FAW, which vary from different regions and countries.

Clinical trial registration

clinicaltrials.gov, identifier (NCT03111875).

Association of Incremental peritoneal dialysis with residual kidney function decline in patients on peritoneal dialysis: The balANZ trial

BACKGROUND

Incremental peritoneal dialysis (PD), defined as less than Full-dose PD prescription, has several possible merits, including better preservation of residual kidney function (RKF), lower peritoneal glucose exposure and reduced risk of peritonitis. The aims of this study were to analyse the association of Incremental and Full-dose PD strategy with RKF and urine volume (UV) decline in patients commencing PD.

METHODS

Incident PD patients who participated in the balANZ randomised controlled trial (RCT) (2004-2010) and had at least one post-baseline RKF and UV measurement was included in this study. Patients receiving <56 L/week and ≥56 L/week of PD fluid at PD commencement were classified as Incremental and Full-dose PD, respectively. An alternative cut-point of 42 L/week was used in a sensitivity analysis. The primary and secondary outcomes were changes in measured RKF and daily UV, respectively.

RESULTS

The study included 154 patients (mean age 57.9 ± 14.1 years, 44% female, 34% diabetic, mean follow-up 19.5 ± 6.6 months). Incremental and Full-dose PD was commenced by 45 (29.2%) and 109 (70.8%) participants, respectively. RKF declined in the Incremental group from 7.9 ± 3.2 mL/min/1.73 m2 at baseline to 3.2 ± 2.9 mL/min/1.73 m2 at 24 months (p < 0.001), and in the Full-dose PD group from 7.3 ± 2.7 mL/min/1.73 m2 at baseline to 3.4 ± 2.8 mL/min/1.73 m2 at 24 months (p < 0.001). There was no difference in the slope of RKF decline between Incremental and Full-dose PD (p = 0.78). UV declined from 1.81 ± 0.73 L/day at baseline to 0.64 ± 0.63 L/day at 24 months in the Incremental PD group (p < 0.001) and from 1.38 ± 0.61 L/day to 0.71 ± 0.46 L/day in the Full-dose PD group (p < 0.001). There was no difference in the slope of UV decline between Incremental and Full-dose PD (p = 0.18).

CONCLUSIONS

Compared with Full-dose PD start, Incremental PD start is associated with similar declines in RKF and UV.

Investigating risk of self-harm and suicide on anniversaries after bereavement by suicide and other causes: a Danish population-based self-controlled case series study

AIMS

To investigate mechanisms of suicide risk in people bereaved by suicide, prompted by observations that bereaved people experience higher levels of distress around dates of emotional significance. We hypothesised that suicide-bereaved first-degree relatives and partners experience an increased risk of self-harm and suicide around dates of (i) anniversaries of the death and (ii) the deceased's birthday, compared with intervening periods.

METHODS

We conducted a self-controlled case series study using national register data on all individuals living in Denmark from 1 January 1980 to 31 December 2016 and who were bereaved by the suicide of a first-degree relative or partner (spouse or cohabitee) during that period, and who had the outcome (any episode of self-harm or suicide) within 5 years and 6 weeks of the bereavement. We compared relative incidence of suicidal behaviour in (i) the first 30 days after bereavement and (ii) in the aggregated exposed periods (6 weeks either side of death anniversaries; 6 weeks either side of the deceased's birthdays) to the reference (aggregated unexposed intervening periods). As an indirect comparison, we repeated these models in people bereaved by other causes.

RESULTS

We found no evidence of an elevated risk of suicidal behaviour during periods around anniversaries of a death or the deceased's birthdays in people bereaved by suicide (adjusted incidence rate ratio [IRRadj] = 1.00; 95% confidence interval [CI] = 0.87-1.16) or other causes (IRRadj = 1.04; 95% CI = 1.00-1.08) compared with intervening periods. Rates were elevated in the 30 days immediately after bereavement by other causes (IRRadj: 1.95, 95% CI: 1.77-2.22).

CONCLUSIONS

Although people bereaved by suicide are at elevated risk of self-harm and suicide, our findings do not suggest that this risk is heightened around emotionally significant anniversaries. Bereavement care should be accessible at all points after a traumatic loss as needs will differ over the grief trajectory.

[Correlation of patient satisfaction with nurses' time spent at the bedside: A prospective observational study]

Correlation of patient satisfaction with nurses' time spent at the bedside: A prospective observational study Abstract. Background: Patient satisfaction is of high importance in quality assurance in many hospitals. The existing shortage of nursing staff and the resulting additional workload for individual nurses reduce the time available for patient care. Aim: The aim of this study is to explore a possible relationship of patient satisfaction with the time spent by nurses at the bedside and the influence of other influencing predictors. Methods: In this observational study, nursing attendance time was collected using attendance records which were verified by digital call light logs, and then evaluated using a linear regression model including patient satisfaction. Results: The nursing attendance time showed no significant influence on "patient satisfaction" (p = 0.155). The most important variables influencing "patient satisfaction" were: "no previous hospital experience" (p = 0.001), "importance of care" (p < 0.001) and "Gender" (form male) (p = 0.001). Conclusions: The time spent by nurses at the patient's bedside is not considered decisive enough to have a clear positive influence on patient satisfaction. Adaptations in nursing care are recommended, which enable a holistic relationship building and goal-oriented nursing care that favours patient satisfaction.

Polyps are detected more often in early colonoscopies

OBJECTIVE

To examine the time variation in polyp detection for colonoscopies performed in a tertiary hospital and to explore independent factors that predict polyp detection rate (PDR).

METHODS

Data on all patients who underwent colonoscopy for the diagnostic purpose at our endoscopy center in Zhongnan Hospital of Wuhan University from January 2021 to December 2021 were reviewed. The start time of included colonoscopies for eligible patients was recorded. PDR and polyps detected per colonoscopy (PPC) were calculated. The endoscopists' schedules were classified into full-day and half-day shifts according to their participation in the morning and afternoon colonoscopies.

RESULTS

Data on a total of 12116 colonoscopies were analyzed, with a PDR of 38.03% for all the patients and 46.38% for patients ≥50 years. PDR and PPC significantly decreased as the day progressed (both p < .001). For patients ≥50 years, PDR declined below 40% at 13:00-13:59 and 16:00-16:59. The PDR in the morning was higher than that in the afternoon for both half-day (p = .019) and full-day procedures (p < .001). In multivariate analysis, start time, patient gender, age, conscious sedation, and bowel preparation quality significantly predicted PDR (p < .001).

CONCLUSIONS

The polyp detection declined as the day progressed. A continuous work schedule resulted in a subpar PDR. Colonoscopies performed in the morning had a higher PDR than that in the afternoon. Patient gender, age, conscious sedation, and bowel preparation quality were identified as the independent predictors of PDR.

Mortality and readmission differences associated with after‐hours hospital admission: A population‐based cohort study in Queensland Australia

Background and Aims

Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after‐hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after‐hours hospital admission.

Methods

Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after‐hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models.

Results

After adjusting for case‐mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after‐hours held true in sensitivity analyses which explored broader definitions of after‐hours care: an “Extended” definition comprising a weekend extending into Friday night and early Monday morning; and a “Twilight” definition comprising weekends and weeknights.

There were no significant differences in 30‐day readmissions for emergency or elective patients admitted after‐hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day‐of‐week effect. Workforce metrics that played a role in observed outcome differences within hours/after‐hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend.

Conclusion

Patients admitted after‐hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

Time course of CYP3A activity during and after metamizole (dipyrone) in healthy volunteers

BACKGROUND AND PURPOSE

In patients of all ages, metamizole is a frequently used analgesic. Recently, metamizole has been identified as an inducer of, among others, cytochrome P450 (CYP) 3A activity, but the time course of this interaction has not been evaluated.

EXPERIMENTAL APPROACH

Using repeated oral microdoses (30 μg) of the CYP3A index substrate midazolam, we assessed changes in midazolam pharmacokinetics (area under the concentration-time curve from 2-4 h: AUC_2-4 and estimated partial metabolic clearance: eCl_met ) before, at steady-state, and after discontinuation of 3 x 1000 mg metamizole/d orally for 8 d.

KEY RESULTS

Significant changes in pharmacokinetic parameters were detected already three days after start of metamizole treatment. At the steady-state of enzyme induction, the geometric mean ratio of midazolam AUC_2-4 was substantially reduced to 0.18 (90 % confidence interval: 0.14-0.24) with a corresponding 5.43-fold (4.15-7.10) increase of eCl_met . After discontinuation of metamizole, the changes slowly recovered, but were still significant at the end of the observation period on the fifth day after discontinuation of metamizole therapy (AUC_2-4 reduced to 0.50 (0.41-0.63) and eCl_met 1.99-fold increased (1.60-2.47, p < 0.05)).

CONCLUSION AND IMPLICATIONS

Metamizole acts as a strong inducer of CYP3A already few days after start of metamizole administration and, thus, should be avoided in patients using drugs with narrow therapeutic index and major clearance via CYP3A. If their administration is essential, close monitoring and dose adjustment of co-medication should be performed as early as the first week after the initiation and after discontinuation of metamizole therapy.

We extended the two-week systematic review (2weekSR) methodology to larger, more complex systematic reviews: a case series

OBJECTIVE

In 2019, we invented the two-week systematic review (2weekSR) methodology, to complete full, PRISMA-compliant systematic reviews in approximately 2 weeks. Since then, we have continued to develop and adapt the 2weekSR methodology for completing larger, and more complex systematic reviews, including less experienced or inexperienced team members.

STUDY DESIGN AND SETTING

For ten 2weekSRs, we collected data on: 1) systematic review characteristics; 2) systematic review teams; and 3) time to completion and publication. We have also continued to develop new tools and integrate them into the 2weekSR processes.

RESULTS

The 10 2weekSRs addressed intervention, prevalence and utilisation questions, and included a mix of randomised and observational studies. Reviews involved screening from 458 to 5,471 references, and included between 5 and 81 studies. Median team size was 6. Most reviews (7/10) included team-members with limited systematic review experience; three included team-members with no prior experience. Reviews required a median of 11 work-days (range: 5-20) and 17 calendar days (range: 5-84) to complete; time from journal submission to publication ranged from 99-260 days.

CONCLUSION

The 2weekSR methodology scales with review size and complexity, offering a considerable time-saving over traditionally conducted systematic reviews without relying on methodological shortcuts associated with 'rapid reviews.'

Esophagogastroduodenoscopy Outcomes Variated by the Time of the Day: A Single-Center Experience

(1) Background: To assess whether the start time influences the outcomes of esophagogastroduodenoscopy (EGD). (2) Methods: We retrospectively analyzed the clinical data of patients who underwent EGD between January 2021 and December 2021 in our endoscopy center. The EGD were divided into three shifts, according to the start time. The lesion detection rate (LDR) and endoscopy biopsy rate (EBR) were used to evaluate the quality of the EGD. (3) Results: A total of 14,597 procedures were included in this study. The LDR of shift 2 was significantly lower than that of shift 1 (62.4% vs. 58.5%; p < 0.001). The EBR of shift 1 (37.4% vs. 31.5%; p < 0.001) and shift 3 (35.5% vs. 31.5%; p = 0.024) were significantly higher than that of shift 2; the EBR in shift 1 did not differ significantly from shift 3 (p = 0.280). The multivariable analysis for the EGD performed before 14:00 demonstrated a graded decrease in the LDR and EBR after adjusting the confounders (p < 0.001). (4) Conclusion: In a continuous working period, the lesion detection and biopsy submission of EGD are superior to those in the first three hours compared to the last three hours; the LDR and EBR decreased as the day progressed, probably due to the endoscopists' fatigue.

Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis

Introduction

Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions.

Methods

The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20^th - March 2^nd, 2020. Patient groups were "routine-hours" (RH): weekdays 07:00-18:59 or "out-of-hours" (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used.

Results

734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis.

Conclusion

Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.